Piece of Mind

Dario Lupi awoke on a hot August morning two years ago and decided it was time to die. The 49-year-old Venezuelan businessman grabbed a bottle of sleeping pills, stuffed it into his jeans pocket, and disappeared from his upscale bayfront condo near the Julia Tuttle Causeway.

He looked remarkably average as he fled: thinning brown hair, a thick mustache, and the faded tan of a man who'd spent years working indoors. But inside he wasn't ordinary; something dark and nagging haunted him.

The date was August 28, 2007. Up in the Charter Club — a cheery salmon-colored building — his wife, Elizabeth Hubinger, began to worry. Elizabeth, an assertive 57-year-old with a soft South American accent, had good reason: Dario had attempted suicide three times before. He had recently talked about the pressures of work and his desire to kill himself.

And now this. Dario was gone and wasn't answering his cell phone. At 11:30 a.m., Elizabeth called Miami Police to report a missing person. She told them he was wearing a yellow T-shirt and had taken off in a 2003 PT Cruiser. Then she waited.

A few hours later, officers found Dario alone in the condo garage. He looked nervous and wouldn't speak or make eye contact. After speaking with Elizabeth, cops made a judgment call: They would take him to the mental health center at Jackson Memorial Hospital.

She was relieved. "I called a friend," Elizabeth remembers. "I said, 'We did it; we saved him. He's going to be OK.'" Then she headed to the hospital with the police.

At 6:42 p.m., Dario arrived at the center, a dreary peach-colored building on NW Ninth Avenue. Officers took him around back to the crisis unit — an emergency room for the mind, filled with dozens of the county's most fragile mentally ill patients.

As Elizabeth spoke to a doctor, a psychiatric aide checked Dario in and then took him to a small, sparse bedroom. Inside were a thin mattress, blank walls, and a cramped bathroom. The aide handed him a cotton shirt and pants, took his belongings, and left him alone. He sat silently on his bed, staring out the window.

An hour passed — according to Jackson documents obtained by New Times — and no doctor had assessed Dario. Though hospital policy states suicidal patients should be under constant supervision, no "safety observation rounds" were documented.

By 8 p.m., an aide returned to the bedroom and heard only the sound of running water. In the bathroom was Dario's lifeless body, dangling by the neck from the shower handle. He had fashioned his cotton pants into a noose and hanged himself.

The suicide is one of many tragedies — at least some preventable — that have plagued the deeply troubled unit of the nation's third-largest public hospital. After reviewing hundreds of pages of state health records, two recent lawsuits, and testimony from three mental health employees, one patient, and a former acting director of the unit, New Times has uncovered the following: rushed patient releases, inadequate supervision, undocumented use of restraints, and possible civil rights violations.

Among the most outrageous cases:

• John Hampton, a homeless 24-year-old, jumped from a parking garage at Jackson after being discharged prematurely in May 2004.

• Doctors ignored confirmed complaints that a woman had been sexually violated by fellow patients in March 2008.

• Shantavia Robinson, a 17-year-old with bipolar disorder, escaped after being shackled repeatedly in April 2008.

• Jacqueline Joyes, a 75-year-old former government secretary, died mysteriously in her bed in April 2008.

Though Jackson ranks at the top of US News & World Report's "Best Hospitals" list, in the past two years, the 172-bed mental health center has been cited for violating state health regulations at least 13 times — more than all ten of Florida's largest psychiatric facilities. (By contrast, Florida State Hospital, which has seven times the number of psychiatric beds, received one such violation in the same period.) State Agency for Health Care Administration (AHCA) findings note everything from the dangerous release of a homicidal woman to the sad story of a patient who lost eight pounds in eight days.

As the state cuts funding for mental health programs, and Florida continues to spend hundreds of millions on ineffective care, one thing is clear: Jackson is failing those who most need it. And state legislators recently pushed aside the only bill meant to fix the problem.

"It felt like a Third-World country," says Lisa Burton, former acting director of patient care, who was fired last year after protesting the shackling of children. "There were absolute atrocities."

Counters Jackson spokesperson Lorraine Nelson: "All regulatory findings are taken extremely seriously. At JHS, we are always looking for ways to improve on the services we provide. Our top priority is and always will be the well-being of our patients."

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John Hampton ended up sleeping on the streets of Miami in May 2004 after he ran away from an adult foster home in New York City. He was a young man with a short beard, a basketball tattoo on his chest, and paranoid thoughts that drove him first to crack cocaine and then to stop sleeping and wearing shoes.

When he arrived at the crisis unit, he was penniless, aggressive, and suicidal. He was "hearing voices and seeing unidentified flying objects," according to state reports. A doctor found no reason to hold the 24-year-old, even though he had been admitted to — and released from — Jackson's mental health center three times in the previous two weeks. Doctors discharged him a fourth time, around 5 p.m. Memorial Day, at which point he became irate.

Nobody stopped him. John's release forms had already been signed and employees were busy dealing with dozens of other patients. At 5:45 p.m., a hospital security guard watched John's 176-pound body drop from the fourth floor of Jackson's Ryder Trauma Center east parking garage and crash into the pavement below. The fall cracked his skull, broke his ribs, and caused his brain to hemorrhage, according to the Miami-Dade Medical Examiner's Office. Fire-rescue rushed him to the main hospital, but it was no use. He was pronounced dead 15 minutes later.

The suicide raises questions about hasty discharges in the understaffed, high-stress facility. A subsequent lawsuit also suggests that after the death, John's medical files were hidden and altered. His records went missing and an employee was later fired for falsifying the documents.

"They were churning out patients," says Freiberg, who still works at the mental health center as an associate nurse manager. "They tried to cover it up."

Jackson's mental health unit was created decades after the main hospital opened in 1918. The center strives to help individuals "gain control over their lives," according to the Jackson Health System website. Because of the hospital's affiliation with the University of Miami, it brings together clinical treatment, teaching, and research.

When Jackson was founded, mental illness meant long-term hospitalization in Florida. In 1971, the Baker Act changed that. Psychiatric wards could no longer involuntarily commit patients for more than 72 hours.

In 1975, a patient named Kenneth Donaldson sued Florida State Hospital in the U.S. Supreme Court, alleging he had been held against his will for 15 years. In the landmark case, the court decided mental illness alone could not justify an involuntary lockup. The ruling prompted a national deinstitutionalization movement. (Critics later blamed it for the spike in homelessness.)

Sharmin Dipnarine, who began working at the mental health unit in 1980, remembers the era as an effective time for psychological treatment. Patients participated in music and art therapy, stayed months, and received fewer psychotropic drugs than today. "It has changed tremendously," says Dipnarine, who retired last year as acting assistant director of nursing. "It became very financially driven."

By the late '90s, public funding had dwindled and hospitals felt a financial pinch. In just eight years, from 1998 to 2006, the number of psychiatric beds in the state halved to 22 per 100,000 people.

So public hospitals began to discharge mentally ill patients sooner. A person who once stayed months would now be out on the street in days. "The pressure is high to release," says Tim Coffey, mental health project coordinator for Miami-Dade County Circuit Court. "Unless someone is saying, 'I'm killing myself right now,' they are getting turned back out. You find they get arrested later for milling around the hospital. It's completely unacceptable."

Jackson was perhaps under more pressure than anywhere in the state. In 2005, the hospital received $76 million from Miami-Dade County to help balance its budget. Two years later, a mental health subcommittee of the Florida Supreme Court, appointed by Chief Justice R. Fred Lewis, released a report criticizing the "fragmented" and "unwelcoming" state of mental health treatment.

Miami-Dade Judge Steve Leifman, a longtime crusader for people with mental illness, was committee chair. He blames the problem on two things: less federal funding and the effects of a tough-on-crime campaign. "It's kind of perfect storm conditions," he explains. "The system is broken."

John Hampton's case is the best example of the dysfunction. At 10:30 p.m. on May 16, 2004, cops first brought him to the mental health center, where he checked in voluntarily. He was suicidal and homeless and had no health insurance. Hospital staff gave him a list of shelters and "discharged the patient to self," according to AHCA reports at 7 the next morning.

Two days later, cops brought him back, this time involuntarily. John was "hearing voices" and "wanted to commit suicide by jumping off a building." Less than 48 hours later, doctors let him go. "The patient... was to follow up with the community health center," AHCA reports note.

He didn't. An ambulance brought him to the hospital's main emergency room for a fractured left hand five days later. He was "physically and verbally abusive" and "wanted to harm himself." A doctor discharged him a third time, at 3:30 p.m. May 27.

The next day, City of Miami Fire-Rescue workers delivered him a fourth time. He was more violent — "homicidal and hallucinating" — according to reports. He stayed until May 31.

Forty-five minutes after he was released, he and a friend, who is not named in public records, climbed about 100 feet to the top of the boxy cement garage across from the mental health center, according to a Miami-Dade coroner's report. Below was a row of small palm trees, a bus stop, and a busy street. They planned to jump together, but security guards spotted the pair and subdued the unnamed companion.

When John's bruised cadaver arrived at the medical examiner's office the next morning, a blue anklet was fastened around his right leg. It read, "34778."

Dipnarine, the 28-year employee, says she believes some staff members were not properly educated or trained. "We weren't tightly structured," she says. "We missed a lot of red flags."

After the death, conflict boiled. Mental health administrators blamed Freiberg, a then-45-year-old nurse manager, for trying to hide the suicide. He was placed on administrative leave in June 2005. According to a lawsuit he later filed, the bosses accused him of "falsifying, stealing medical records, and destroying hospital property."

Freiberg says someone else "doctored the records" in order to hide the fact that John had threatened suicide before release. Indeed, Jackson administrators soon learned the nurse manager wasn't responsible. After reviewing evidence, authorities rehired him two years later. (The lawsuit was eventually dropped.)

Jackson did not respond to inquiries about the stolen records noted in the lawsuit.

Today, Florida spends more than $789 million per year on mental health treatment, roughly the budget for natural disaster preparation and highway safety combined. Though the Sunshine State is among top spenders, it repeatedly ranks among the lowest in terms of care, according to the National Alliance for People with Mental Illness. A 2009 report graded Florida's system with a D. It dropped from a C in 2008.

Jackson spokesperson Lorraine Nelson couldn't speak specifically about John Hampton's case. "Due to confidentiality laws, we cannot comment on the care provided to a patient without consent." She added, "Jackson Health System complies with all regulatory laws and guidelines for the treatment and reporting of patient care."

But more tragic tales would surface.

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A circle of men with wild hair and ripped clothes drinks beer from cans on a sidewalk half a block from Jackson's Highland Park psychiatric unit. The lonesome mud-colored building stands across from the main mental health center on the eastern outskirts of the mammoth medical complex. Inside a vacant lobby, a pretty security guard with bright pink nails gabs on her cell phone. "Oh, nothing," she says. "Just at work, bored."

Hospital policy states the facility should be tightly monitored to prevent escapes and intrusion, but a New Times reporter strolls by the guard and over to a set of locked elevators. After a few minutes, the doors squeak and then spontaneously part, and New Times climbs in. Brown paint peels off the elevator walls like dead tree bark.

On the fourth floor, a few staff members chat behind a desk. Nearby, a large rectangular window shows several patients in a locked room. One of them — a tall, restless man with the build of a point guard — wears black scrubs and an intense facial expression. He paces, stops in front of the window, and stares out with a wrinkled brow. Next to him, a sign with a smiley face reads, "Only smiles and good attitudes." New Times doesn't enter the patient area. But the point is made: Oversight is weak.

Or perhaps negligence is just the beginning. Over the past two years, state health investigators have found everything from a failure to prevent abuse to illegal shackling of patients. Other complaints range from urine stench to physical abuse from an aide. Things were so bad that on March 28, 2007, authorities threatened to pull the plug on Jackson's Medicare funding.

"The conditions at your hospital pose an immediate and serious threat to the health and safety of patients," reads a letter to Jackson CEO Marvin O'Quinn from Sandra Pace, the associate regional administrator for the Centers for Medicare & Medicaid Services. "The Medicare provider agreement... is being terminated at the close of business April 15, 2007."

The letter was prompted by a state inspector's three-day unannounced visit to the unit. In 62 pages of never-before disclosed notes, the report describes dreadful conditions. Altogether, the findings expose a disregard for patients' rights, safety, and personal privacy. Many were suicidal. Others were delusional, homicidal, or paranoid.

It began on a Tuesday morning. The inspector, Marlen Morales, arrived at the center March 20, 2007, after an anonymous tipster called to complain. That day, Morales checked the records of a 29-year-old woman with a borderline personality disorder. She had slashed both wrists and swallowed 60 muscle relaxant pills. Though nurses recorded the young woman was sleeping, documents revealed she was in an emergency room "attempting to leave," Morales wrote. The patient should have been under "constant observation."

She was discharged the following day, although medical records state "she continues to have thoughts of killing herself."

The same day, a female patient with chronic depression and no health insurance told doctors she would kill herself and her abusive husband if she were sent home. Even so, a physician ordered she be discharged in less than 24 hours. Morales determined she hadn't met "the criteria for an appropriate discharge."

The next day, the inspector noticed an out-of-touch female patient in the communal area of the crisis center. Her gown was on backward and her "breast and chest were exposed." Male patients were present, but "no staff intervened" to help.

Though the facility was slammed with people in need, a nurse director told the AHCA investigator "the hospital does not have enough staff" and therefore "89 to 99 [of the then-239] patient beds are not occupied."

Adds former hospital assistant director Dipnarine: "There was a point we were trying to cut staff. It's possible we cut it too close."

All in all, the unit was cited five times during the visit. The staff "failed to provide supervision," "failed to prevent abuse," and "failed to properly assess patients." Jackson corrected the violations April 12, 2007, and funding wasn't terminated. But the next year, the mental health unit was again cited — seven times.

On February 14, 2008, an inspector named Mildred Kincaid found nursing staff allowed a 225-pound male patient with special dietary needs to lose a pound a day for more than a week. There was "no documentation" anything had been done to help him even though the patient complained, state records show. By April, inspectors found "the deficiencies... [had] been corrected."

But the next month, inspector Morales returned without warning. She found long phone cords and damaged thermostats, which were suicide risks. She noted the hospital "failed to make needed repairs" and "failed to maintain a clean and sanitary environment."

The same week, after examining an incident log and interviewing three staff members, Morales discovered the following: Just after breakfast on March 28, 2008, an aide had discovered a "confused and vulnerable" woman locked in a bathroom with two male patients. She stood incoherent as the strangers — a 21-year-old and 36-year-old — tried to undress her. One of the men was delusional; he believed she was his wife.

The woman then reported to staff that the men had sexually assaulted her. According to state regulations, police should have been called and she should have been transported to a rape treatment center. But nothing was done.

Morales "substantiated" the abused woman's claim and again cited Jackson, this time for four violations, including failure to "prevent abuse," "honor patient rights," and "ensure policies after an alleged sexual abuse."

Perhaps most striking of all, according to the report: A doctor was aware of the situation but stated, "No, I'm not going to call the police on this."

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Shantavia Robinson, a blunt, voluptuous 17-year-old, was an inpatient at Jackson's adolescent psychiatric program in April 2008. She had bipolar disorder but through good behavior earned the privilege of an outing with her case manager to Trinity Church at NW Second Avenue and 177th Street. She was a foster kid who had a nickel-size scar on her left cheek and the word savage tattooed across her chest.

Soon after arriving at the tall, white church building, she turned to size up her supervisor: high heels, good posture, and a tidy hairdo. Ain't no way this lady's gonna chase me, she thought.

So as the elegant case manager filled out paperwork, Shantavia excused herself and headed to the bathroom. Then she slipped out a side door and sprinted across a busy highway. After passing a cluster of long brown houses, she entered a Wal-Mart and hid there until a gang member she calls "my brother" picked her up.

Shantavia says she had good reason for running: During a three-month stay at Jackson's Statewide Inpatient Psychiatric Program (SIPP), she was repeatedly shackled with locked fabric restraints, much like those worn by hardened criminals in jail. The restraints were the consistency of a seat belt, used to bind her wrists and ankles as she was transported to court and doctor's appointments. She also claims to have been strapped to tables, verbally abused, and given shots in the buttocks to make her pass out.

"It made me feel like an animal," she says. "They'd strap those shackles on tight. Didn't matter how calm I was."

Shantavia's story is dramatically intertwined with that of Lisa Burton, who last year was fired as acting director of patient care for mental health services after protesting inappropriate use of restraints. In a lawsuit filed this past May, Burton claims troubled children and adolescents such as Shantavia were frequently shackled without proper assessment because of understaffing. Her complaint, which is filed under the Americans with Disabilities Act, asks that she be rehired.

"I want this to stop," Burton says. "These are the sickest, most vulnerable people in society. A lot of them are foster children who have no one."

Responds Jackson spokesperson Lorraine Nelson: "The mental health hospital at Jackson Memorial Hospital uses walking restraints on less than 1 percent of its patients when they are being transported outside the MH facility. The fabric restraints are only used as a last resort after a board-certified psychiatrist has reviewed the patient's circumstances and when a patient is determined to be a flight risk." She could not comment on Shantavia's case or the details of Burton's lawsuit.

Shantavia Andrea Robinson was born July 2, 1990, to a crack-addicted mother named Janice. Her father, Nick, collected disability checks and had more kids than he could count on both hands. She was raised by her great-aunt in a four-bedroom apartment in Carol City. At age 12, she was sent to live with a foster family. A teacher sexually assaulted her the same year, she says.

By the time Shantavia was 17, she had seen the inside of six foster homes. "I always had anger inside me because of my mom," she says. "I started fighting a lot."

Her friend Carolyn Ware — a thin 47-year-old with red streaks in her hair — explains Shantavia began living on the streets. "She's got a good heart but a quick temper," says Ware, standing outside her run-down Miami Springs home. "Her craziness would flare up."

Around the same time, Miami-Dade Circuit Court Judge Sarah Zabel began hearing scary stories about the children's psychiatric unit at Jackson. Young patients complained staff pushed them around, screamed, and left them in shackles for long periods. And Zabel believed them. "These kids are bright," Zabel says. "You listen and they are all telling the same story. You have to believe something is going on."

Indeed, an AHCA investigation that year revealed staff did not keep adequate records of restraints and that they passed out meds without "appropriate informed consent or court orders."

Two years later, Miami-Dade public defender Carlos Martinez watched as a troubled three-foot-seven-inch 11-year-old girl bound by her wrists and legs was led into court. "The emotional and psychological effects are scarring," he says. "When we shackle kids, we are telling them that they are bad. We are punishing them before we even know if they've done anything wrong." He pushed to have indiscriminate shackling halted in Miami-Dade courts and succeeded.

But it never stopped inside Jackson. In 2007, soon after inspectors discovered the hospital improperly restrained a suicidal 29-year-old, Shantavia was sent to the psychiatric care unit. When she learned she would be staying for months, she became indignant: "I was like, Hell, no."

Soon her life became regimented. She would awake at 5:30 a.m., attend class, take her pills, and eat a tasteless dinner. Medication made her feel sluggish, and she gained almost 100 pounds. Perhaps to rebel, she began having sex with her roommate, who was a "fine-ass Cuban girl," she says. In the first month, she attempted to escape and was caught.

No matter how well Shantavia behaved, each time she had to be transported, nurses would strap on the shackles, she says. "People would stare. Oh my God, that was embarrassing."

Lisa Burton had never seen the word shackles in a doctor's order until she arrived at the hospital near the end of Shantavia's stay. Burton — a principled 51-year-old brunette — was hired March 24, 2008. She had worked 25 years in the medical field, much of it in mental health, but had never seen conditions like those at Jackson.

Burton was hired as the associate director of patient care services, a $115,000 administrative position. She was impressed with the dedicated nursing staff but found administration encouraged "fear and silence." Within her first two weeks, while doing a safety inspection, she found decapitated birds and dead mice in the Highland Park unit. She snapped photographs and reported it to her supervisor. Her boss told her not to bring it up again, she says.

Adds co-worker Dipnarine: "Lisa Burton came in with fresh eyes. She had knowledge and energy."

On the evening of April 15, Burton discovered something worse: An order to shackle an adolescent girl. Federal mental health law states shackles cannot be used for punishment or convenience and should be used only in an emergency. But in this case, the orders were written five days in advance. "I was stunned," Burton says. So she asked a nurse to lock her into the fabric shackles in order to get a sense of how it felt. She then reviewed a chart and found the practice was widespread.

The next day, Burton was appointed to a higher-ranking position: acting director of patient care. She was given more responsibility and a pay increase. When she informed hospital regional director Melida Akiti about the shackles and safety conditions, the $168,000-per-year official "demanded Burton to keep quiet," the lawsuit notes. Burton was outraged and met with others who agreed to "cease the use of shackles" in the adolescent unit April 18.

Three days later, Akiti called in Burton and offered a severance package, according to the lawsuit. It included a confidentiality agreement. Burton declined and was escorted by a security guard off the premises. She later filed a whistleblower complaint with the county ethics commission and lost. (The reason, according to ethics commission documents: She had failed to file "a written and signed complaint" when reporting the shackling.)

Shantavia fared worse. After fleeing the hospital, she began selling drugs with a boyfriend. Since then, she's been arrested for throwing a rock through a window and aggravated assault with a knife. (In both cases, charges were dropped.) Of her time at Jackson, she says, "They think they're helping. Really, they fuck you up more."

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If you consider Shantavia Robinson nothing more than a miscreant who deserved shackling, consider the case of Jacqueline Crawford Joyes. Born an only child June 8, 1932, she grew up traveling the world with her homemaker mother and her stepfather, a military colonel. Her birth father died when she was 7.

She battled depression, worked as a government secretary, and went on medication as an adult, says her cousin, Linda Kellogg. Jacqueline was a deeply religious loner who never married. At age 40, she lived with her parents in a spacious Coral Gables home. "She did better with the help of chemicals," remembers Kellogg, who now lives in California. "She used to write me such sweet letters."

One morning in 1979, her stepfather woke up, took out a gun, and shot his wife and then himself. Jacqueline found their bodies. "It really sent her over the edge," Kellogg remembers. "She had no one."

That year, a judge found she was unable to care for herself. Because she had no family nearby, a Miami attorney named Charles Johnson became her legal guardian in the late '90s. The gray-haired University of Florida alum helped her check into Epworth Village Retirement Community in Hialeah. There she would watch television and occasionally leave her room for birthday parties. "She was somewhat reclusive," Johnson says. "But she was content."

Then, on April 3, 2008, she snapped. "All of a sudden, I get a call she had checked in to Jackson Memorial," Johnson says. "I was happy to have her in what I thought was a reputable facility."

He met her there a few hours later and greeted her in what looked like a "holding cell," he says. About eight other patients were inside and Johnson suspected they were all waiting to be evaluated. Jacqueline was alert but wouldn't look at him. "The only thing she would say is 'I want to die,'" he remembers. "I have no idea what got her to that point."

At 5:43 a.m. April 4, 2008, within 24 hours of checking in, an aide found the chubby, fair-skinned 75-year-old dead inside her room in the psychiatric unit. "It was very suspicious," says Burton, who was then associate director. "She was supposed to be on 15-minute checks." No cause of death was ever determined.

Indeed, public records confirm no autopsy was conducted. "We don't know how long she went undiscovered," Johnson says. "Whether they took too long to evaluate her, I don't know."

Like pre-Jackson attempts to save Jacqueline Joyes's life, efforts aimed at fixing the psychiatric unit have failed. This past April, committees for the Florida Senate and House of Representatives considered something called the Community Mental Health & Substance Abuse Treatment & Crime Reduction Act. Its goal, in part, was to help remove pressure on state psychiatric crisis centers such as the one at Jackson. The act's concept was simple: Catch and treat people with mental illness before they end up in jails and emergency rooms. Put money into community-based prevention. And save millions in the process.

The legislation represented years of work by public and private leaders such as Miami-Dade Judge Steve Leifman. The bright, bespectacled jurist spent months meeting with the right people: politicians, reps from the Department of Children and Families, and community advocates. "It's a remarkable piece of legislation," he told New Times a couple weeks before the session closed.

Nearly every major newspaper in Florida editorialized in favor of the bill. The Miami Herald noted it would "save the state hundreds of millions." The St. Petersburg Times explained, "Florida cannot afford not to move in this direction."

But when it came time for the vote, politicians were bombarded with budget issues. Some believed there would be unanticipated costs. The bill made it through several Senate and House committees before the session ended. It never reached a floor vote. "It was overshadowed by so many other issues," says mental health project coordinator Coffey, who worked with Leifman on the act. "Anything that didn't relate to the budget got pushed aside."

It will likely go before the House and Senate again next year. Says Leifman: "[The current system] is the definition of insane... There's a better way to do this."

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